1. Postoperative Pulmonary Edema R1 謝佩芳

2. Postoperative Pulmonary Edema Half the patients with perioperative pulmonary edema have preoperative evidence of cardiovascular disease. Ann Surg 172:883, 1970

3. Conditions Leading to Pulmonary Edema, Acute Lung Injury, and ARDS Altered Permeability State Acute radiation pneumonitis Aspiration of gastric contents Drug overdose Near-drowning Pancreatitis Pneumonia Pulmonary embolus Shock states SIRS and multiple organ failure Sepsis Transfusion Trauma and burns Increased Hydrostatic Pressure Acute left ventricular failure Chronic congestive heart failure Volume overload Thoracic lymphatic insufficiency Obstruction of LVOT Mixed or Incompletely Understood Pathogenesis Hanging injuries High-altitude pulmonary edema Narcotic overdose Neurogenic pulmonary edema Postextubation obstructive pulmonary edema Re-expansion pulmonary edema Tocolytic therapy Uremia Sabiston Textbook of Surgery, 17th ed.

4. Postoperative Pulmonary Edema Cardiogenic causes LV dysfunction (MI, Heart failure) Non-cardiogenic causes Aspiration pneumonitis Fluid overload Post-obstructive lung edema Chest 1999; 115(5): 1371-1377

5. Postoperative Pulmonary Edema Non-cardiogenic causes Neurogenic pulmonary edema secondary to postoperative hyponatremic encephalopathy Head trauma Pheochromocytoma Chest 1999; 115(5): 1371-1377

6. Postobstructive Pulmonary Edema Etiology Large negative intrathoracic and transpulmonary pressure. These have generally been reported to be secondary to trying to inspire against an obstructed airway. Some authors feel young healthy patients- especially male athletes- are at higher risk because of the ability to generate greater negative intrathoracic pressure. Causes obstructive sleep apnea mediastinal tumor oropharyngeal surgery Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

7. Postobstructive Pulmonary Edema Causes Laryngospasm (the most common cause) Strangulation Epiglottitis Foreign-body aspiration hypothyroidism, thyroid goiter hiccups croup TMJ arthroscopy Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

8. Postobstructive Pulmonary Edema Causes hematoma difficult intubation biting of a laryngeal mass raised airway resistance in intubated patients inspissated tracheal secretions upper airway tumor obesity acromegaly Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

9. Postobstructive Pulmonary Edema Clinical presentations sudden onset of dyspnea, tachypnea, hypoxemia, hypercapnia, and pink frothy secretions after relief of airway obstruction The onset is usually within minutes of relief of upper airway onstruction, but some may not develop for several hours. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

10. Postobstructive Pulmonary Edema Clinical presentations CXR: a widened vascular pedicle with centralized bilateral alveolar and interstitial infiltrates Rapid onset and resolution, with the significant clinical and radiographic improvement in 12 to 24 hours. Cardiogenic etiology and aspiration pneumonia should be entertained Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

11. Postobstructive Pulmonary Edema Incidence The incidence has been report in the literature to be up to 11%, with a special predilection for head and neck patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

12. Postobstructive Pulmonary Edema Treatment Positive pressure ventilation during the phase of laryngospasm If prolonged laryngospasm (ie, greater than 30 seconds), consideration should be given to the administration of SCC 1 mg/kg, followed by intubation and mechanical ventilatiion. Patients frequently require at least physiological PEEP (5 mmHg) Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

13. Postobstructive Pulmonary Edema Treatment Diuretics: controversial; furosemide 0.5~1 mg/kg, commonly reserved for patients with marked hypervolemia from aggressive intraoperative hydration Hemodynamic monitoring ECG and serum troponin may be indicated to rule out cardiac injury Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:4-6

14. Treatment of Postoperative Pulmonary Edema Lowering hydrostatic pressure in the lungs to the lowest possible level consistent with adequate perfusion of all organ systems. Diuretics, fluid restriction, vasodilator Dialysis if associated renal failure is present Positive-pressure ventilation with PEEP to increase lung volume Miller’s Anesthesia, 6th ed.

15. For this patient... No previously cardiac, pulmonary, kidney or liver dysfunction Normal preoperative EKG, CXR, BUN/CRE, AST/ALT level No blood transfusion Not overhydrating intraoperatively Rapidly resolution

16. For this Patient Check EKG and cardiac enzyme to rule out cardiogenic pulmonary edema May consider positive pressure ventilation with PEEP if still de- saturated

17. Thank You!!